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Holistic Yoga Therapy New Client Intake Form
Name
*
First Name
Last Name
Email
*
Phone
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Best way to get ahold of you
Text
Email
Birth Date
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DD
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Occupation:
What is your predominant reason for seeking yoga therapy at this time?
Do you have or have had
High blood pressure
Glaucoma
Osteoporosis
Seizures
Diabetes
Rheumatoid arthritis
Anemia
Heart problems
Asthma
Other breathing problems
Dizziness, vertigo or loss of balance
Unexplained falls or fractures
Hearing difficulty
Hernia/rupture
Unstable/ "trick" joint(s)
Hearing difficulty
Metal implants/artificial joints
Bladder or bowel control problems
Pinched nerves or disc problems
Cancer
Broken bones
Allergies
Blood thinners
Neurological diseases
Headaches
Vision difficulties
Chest pain
Shortness of breath
Night sweats
Joint swelling
Traumatic auto accidents
Major surgeries
Other chronic conditions (women only)
Hysterectomy
Menopausal challenges
Caesarean delivery
Early termination of menses
Do any of the following currently apply?
Back problems
Hernia
Joint problems
Epilepsy
Arthritis
Low blood pressure
Hypoglycemia
Chronic fatigue
Anxiety/depression
Please list any recent surgeries:
Medications and supplements that you are currently taking:
Have you experienced other health problems or challenges in your life?
Do you experience pain in any part of your body –on occasion, acute or chronic?
Tell me a little about your lifestyle? Diet? Exercise program? Do you smoke or drink?
How is your breathing?
How would you describe your energy levels?
How is your stress level?
What types of situations trigger stress or bring it on for you?
What are some of the ways you find most effective for releasing stress?
Do you awaken from sleep feeling rested? Do you fall asleep easily?
How do you have fun in your life?
How well do you feel you nourish yourself –with food, love and laughter?
How would you describe your state of mind most of the time?
How would you describe your spiritual or religious life?
What is your experience with Yoga, meditation or other spiritual practices?
How often do you practice and is your practice regular?
What have you found most beneficial from these practices?
What have you found most difficult or challenging?
Do you have any other comments/concerns?
Thank you!
